Are restraints all bad?

Attitudes of Nursing Staff Toward Restraint Use in Long-Term Care

Although legislation has forced discretion in using physical restraints for institutionalized elders, considerable discussion continues about this matter. In particular, decision making around restraint use is not adequately understood. Awareness of the perceptions of nursing staff, who are usually involved in most decisions about restraint use, would be helpful to an understanding of the continued use of restraints. This study examined attitudes held by staff in long-term care settings and explored relationships of education and employment characteristics to physical restraint use. Licensed and unlicensed nursing personnel (N = 140) from 4 long-term care facilities were surveyed using a previously developed questionnaire. Results of stepwise regres sion showed that concerns about resident falls, resident disability, and staff harm explained a large portion of the variation in recommendations regarding restraint use Other findings suggest there is reason to believe improvements in perceptions about restraint use are occurring. Implications for staff education and areas for change in the work environment are provided

A synthesis of what we know about the use of physical restraints and seclusion with patients in psychiatric and acute care settings: 2003 update

PURPOSE

This article is an update of the January 19, 2000, Volume 7, Number 2 article of the synthesis of research findings on the use of restraint and seclusion with patients in psychiatric and acute care settings.

CONCLUSIONS

The little that is known about restraint/seclusion use with these populations is inconsistent. Attitudes and perceptions of patients, family, and staff differ. However, all patients had very negative feelings about both, whether they were restrained/secluded or observed by others who were not restrained. The reasons for restraint/seclusion use vary with no accurate use rate for either. What precipitates the use of restraint/seclusion also varies, but professionals claim they are necessary to prevent/treat violent or unruly behavior. Some believe seclusion/restraint is effective, but there is no empirical evidence to support this belief. Many less restrictive alternatives have been tested with varying outcomes. Several educational programs to help staff learn about different ways to handle violent/confused patients have been successful.

IMPLICATIONS

Until more is known about restraint/seclusion use from prospective controlled research, the goal to use least restrictive methods must be pursued. More staff educational programs must be offered and the evaluation of alternatives to restraint/seclusion pursued. When seclusion/restraint is necessary, it should be used less arbitrarily, less frequently, and with less trauma. As the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Health Care Financing Administration (HCFA) have prescribed, "Seclusion and restraint must be a last resort, emergency response to a crisis situation that presents imminent risk of harm to the patient, staff, or others" (p. 25) [99A].

Restraint reduction reduces serious injuries among nursing home residents

OBJECTIVES

To describe how removing physical restraints affected injuries in nursing home settings.

DESIGN

A 2-year prospective study of an educational intervention for physical restraint reduction.

SETTING

Sixteen diverse nursing homes with 2075 beds in California, Michigan, New York, and North Carolina.

PARTICIPANTS

Study A: 859 residents who were physically restrained at the onset of the intervention on October 1, 1991. Study B: all residents who occupied the 2075 beds in the 16 facilities 3 months before the intervention and 3 months after its completion.

INTERVENTION

Educational program for nursing home staff followed by quarterly site consultations to participating nursing homes.

MAIN OUTCOME MEASURES

Rate of physical restraint use and injuries.

RESULTS

Study A: Serious injuries declined significantly among the 859 residents restrained initially when restraint orders were discontinued (X2 = 6.2, P = .013). Study B: During the intervention period, physical restraint use among the 2075 residents decreased from 41% to 4%, a 90% reduction. The decrease in the percentage of injuries of moderate to serious severity was significant (i.e., 7.5% vs 4.4%, P2-tail = .0004) as was the rate of moderate and serious injuries combined (Rate Ratio = 1.580, P2-tail = .0033).

CONCLUSIONS

A substantial decrease in restraint use occurred without an increase in serious injuries. Although minor injuries and falls increased, restraint-free care is safe when a comprehensive assessment is done and restraint alternatives are used.

Geropsychiatric restraint use

OBJECTIVES

To investigate predictors and reasons for restraint use with geropsychiatric patients.

DESIGN

A prospective, correlational study.

SETTING

The geriatric unit of an acute-care psychiatric hospital.

PARTICIPANTS

Twenty-one staff nurses and 131 patients admitted consecutively over a period of 6 months.

MEASUREMENTS

Disruptive behaviors were measured with the Nursing Home Behavior Problem Scale (NHBPS), cognitive function was measured with the Mini-Mental State Examination (MMSE), mobility was measured with a Functional Mobility Screen (FMS), and reasons for restraint use were obtained with a questionnaire completed by nurses.

RESULTS

Patients with a diagnosis of dementia, impaired mobility, or behavioral problems were more likely to be restrained. The most frequent reasons given by staff for restraint use were an unsteady gait and a risk of falling. The incidence of restraint use was 27.1%.

CONCLUSIONS

The use of restraint with geropsychiatric patients may be more common than previously reported and requires further investigation.

Reducing and managing restraints in long-term-care facilities

OBJECTIVE

To evaluate a management system designed to improve staff adherence to a federal regulation that stated restrained residents should be released, exercised, and repositioned every 2 hours.

DESIGN

A delayed intervention, controlled, cross-over design with three phases. During phase one, baseline, the length of intervals that residents remained in restraints was monitored. The intervention was implemented at site A in Phase two while site B remained in baseline. During Phase three, the intervention was replicated at site B.

SETTING

Two long-term care proprietary nursing facilities.

PATIENTS

Sixty-three physically restrained residents in the two facilities.

INTERVENTION

The intervention was a system of restraint release using colored pads corresponding to specific hours. The management rule was that the resident should be on a different colored pad every 2 hours. Staff had to lift residents to place the pad, and the colors made the system easy for supervisors to check.

MAIN OUTCOME MEASURES

Checks by research personnel by black light and invisible ink, to detect movement of the knot tying the restraints.

RESULTS

During the baseline phase, the majority of residents at both sites were inappropriately restrained longer than 2 hours (site A: 54.1%; site B: 60.1%). The percentage of residents restrained over 2 hours was significantly reduced during the intervention phase to 13.9% (site A) and 19.4% (site B). Three weeks after the end of the intervention, inappropriate use of restraints remained low, 14.2%, but rose to 47.7% after another 3 weeks.

CONCLUSION

The management system is an effective way to increase the consistency with which nursing-home staff release and reposition restrained residents.